Aortic Complications Spike for Women During Pregnancy and Shortly After Giving Birth
A large analysis involving millions of women is shoring up the case that pregnancy is a particularly high-risk time for developing aortic dissection and rupture. Women with a connective tissue disorder and those with hypertension were particularly vulnerable, researchers found, but even seemingly healthy women were more likely to develop the complication while pregnant or postpartum than they were 1 year later.
“For many, many decades a lot of clinicians have felt that pregnancy can trigger these kinds of aortic complications. Certainly there are dozens of case series,” lead author Hooman Kamel, MD (Weill Cornell Medicine, New York, NY), told TCTMD. But there have always been skeptics, he said, with some questioning whether the risk only seems higher because pregnancy increases the likelihood that complications will be reported and studied.
While a link was suspected, “there hadn’t been a really robust study with a control group demonstrating a significant association between pregnancy and these outcomes,” Kamel explained.
Risk Quadrupled With Pregnancy
Published online August 4, 2016, in Circulation, the analysis is based on administrative claims data of emergency department visits and acute care hospitalizations at nonfederal healthcare facilities in California, Florida, and New York between 2005 and 2013. In all, there were 6.6 million pregnancies in 5.9 million women.
Thirty-six women had aortic dissection or rupture either during pregnancy or within 3 months after delivery. For a control group, the researchers looked at an equivalent 270-day period exactly 1 year later for comparison in each woman, identifying nine cases.
Aortic complications developed in 5.5 per million women during pregnancy/postpartum and 1.4 per million women during the control period (incidence rate ratio [IRR] 4.0; 95% CI 2.0-8.2).
Women with a documented connective tissue order had a sharply higher rate of aortic dissection or rupture: 4,960.6 cases per million versus 4.9 per million in women without this diagnosis (P < 0.001 for interaction). Even among women without a connective tissue disorder, pregnancy was still linked to higher risk (IRR 3.6; 95% CI 1.7-7.3).
For women with preexisting hypertension, aortic complications occurred at a rate of 106.2 per million individuals during pregnancy and 42.6 per million 1 year later.
Risk did not differ significantly depending on whether women were pregnant for the first or second time, by mode of delivery, or by the presence or absence of preeclampsia/eclampsia.
What Can Be Done
As part of good antenatal care, women with hypertension—whether diagnosed previously or during pregnancy—merit extra attention, Kamel advised. “They are certainly at high risk both for these events but also for other events that are probably even more common like preeclampsia and neurological complications.” Blood pressure should be checked regularly, he said, and any kind of elevation taken seriously.
Moreover, for women with a known connective tissue disorder, the findings support existing guidelines that they “be closely monitored for enlargement of their aorta as they go along during their pregnancy,” he said.
Emergency medicine doctors and ob-gyns caring for pregnant women in general should also be aware of the potential for aortic complications, Kamel stressed. “They’re very rare, but if a patient is presenting with symptoms that are consistent with an aortic dissection or rupture, there should be a higher index of suspicion during or shortly after pregnancy. . . . These can be pretty dramatic presentations, and it’s a very dangerous and lethal disease if patients don’t come to medical attention quickly.
Despite the excess risk, Kamel cautioned against overscreening, however, given that some tests for diagnosing aortic complications have risks, particularly during pregnancy.
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Kamel H, Roman MJ, Pitcher A, Devereux RB. Pregnancy and the risk of aortic dissection or rupture: a cohort-crossover analysis. Circulation. 2016;Epub ahead of print.
- Kamel reports no relevant conflicts of interest.